Frozen Shoulder

Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain. Adhesive capsulitis is a painful and disabling condition that often causes great frustration for patients and caregivers due to slow recovery. Movement of the shoulder is severely restricted. Pain is usually constant, worse at night, and when the weather is colder; and along with the restricted movement can make even small tasks impossible. Certain movements or bumps can cause sudden onset of tremendous pain and cramping that can last several minutes. This condition, for which an exact cause is unknown, can last from five months to three years or more and is thought in some cases to be caused by injury or trauma to the area. It is believed that it may have an autoimmune component, with the body attacking healthy tissue in the capsule. There is also a lack of fluid in the joint, further restricting movement. In addition to difficulty with everyday tasks, people who suffer from adhesive capsulitis usually experience problems sleeping for extended periods due to pain that is worse at night and restricted movement/positions. The condition also can lead to depression, pain, and problems in the neck and back. Risk factors for frozen shoulder include diabetes, stroke, accidents, lung disease, connective tissue disorders, and heart disease. The condition very rarely appears in people under 40. Treatment may be painful and taxing and consists of physical therapy, medication, massage therapy, hydrodilatation or surgery. A doctor may also perform manipulation under anesthesia, which breaks up the adhesions and scar tissue in the joint to help restore some range of motion. Pain and inflammation can be controlled with analgesics and NSAIDs. The condition tends to be self-limiting: it usually resolves over time without surgery, but this may take up to two years. Most people regain about 90% of shoulder motion over time. People who suffer from adhesive capsulitis may have extreme difficulty working and going about normal life activities for several months or longer.

Presentation

Movement of the shoulder is severely restricted, with progressive loss of both active and passive range of motion.[1] The condition is sometimes caused by injury, leading to lack of use due to pain, but also often arises spontaneously with no obvious preceding trigger factor (idiopathic frozen shoulder). Rheumatic disease progression and recent shoulder surgery can also cause a pattern of pain and limitation similar to frozen shoulder. Intermittent periods of use may cause inflammation.

In frozen shoulder, there is a lack of synovial fluid, which normally helps the shoulder joint, a ball and socket joint, move by lubricating the gap between the humerus (upper arm bone) and the socket in the scapula (shoulder blade). The shoulder capsule thickens, swells, and tightens due to bands of scar tissue (adhesions) that have formed inside the capsule. As a result, there is less room in the joint for the humerus, making movement of the shoulder stiff and painful. This restricted space between the capsule and ball of the humerus distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, or heart disease are at a higher risk for frozen shoulder. Injury or surgery to the shoulder or arm may cause the capsule to tighten from reduced use during recovery.[2] Adhesive capsulitis has been indicated as a possible adverse effect of some forms of highly active antiretroviral therapy (HAART). The condition rarely appears in people under 40 years old and, at least in its idiopathic form, is much more common in women than in men (70% of patients are women aged 4060). Frozen shoulder in diabetic patients is generally thought to be a more troublesome condition than in the non-diabetic population, and the recovery is longer.

Prevention To prevent the problem, a common recommendation is to keep the shoulder joint fully moving to prevent a frozen shoulder. Often a shoulder will hurt when it begins to freeze. Because pain discourages movement, further development of adhesions that restrict movement will occur unless the joint continues to move full range in all directions (adduction, abduction, flexion, rotation, and extension). Physical therapy and Occupational therapy can help with continued movement.

Signs and diagnosis

One sign of a frozen shoulder is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. The movement that is most severely inhibited is external rotation of the shoulder. People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion, or if bumped. A physical therapist may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder). An arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.

The normal course of a frozen shoulder has been described as having three stages: Stage one: The "freezing" or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion. Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to nine months. Stage three: The "thawing" or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months.

Imaging A native x-ray of a frozen shoulder is usually inconspicuous. At the best there is sometimes a slight osteopeny due to the biomechanical inactivity or a discrete humeral head elevation due to the shrinkage of the capsule. In addition, physiologically age-related degenerative changes like calcium deposits may also be present and should not lead to a false positive diagnosis. Arthrography of the glenohumeral joint has for a long time been considered to be the only reliable diagnostic tool for a frozen shoulder. Given the possible multitude of risks and complications, it should nowadays only be applied restrainedly. The sometimes significantly reduced capsule volume, down to only 10-12 ml, has been documented repeatedly through arthrography. It often showed an irregular limitation of the joint space and its outline. Additionally there is often to see a variable filling of the inferior recesses, the subscapular bursa and the biceps tendon sheath. An association between capsular shrinkage and restricted movement has been described. However, correlation between the arthrographic diagnosis and the

prognosis are contradictory. 6-10% of patients with a frozen shoulder have had an inconspicuous arthrography.

Ultrasonography The sonographic examination of the periarticular soft tissues can only provide circumstantial evidence for a frozen shoulder. Ultrasonographic equivalences of tendo-synovial involvement at the frozen shoulder are thickening of the tendon itself (found in 18.5%) or a hypoechoic yard, a so-called halo phenomenon (found in 42.6%). Compared to the same findings at an adhesive subacromial syndrome of 3.1%, respectively, 13.8%.

Scintigraphy In the frozen shoulder is often an increased accumulation of 99Tc pertechnetate or 99Tc diphosphonate to find. With a positive correlation between increased accumulation and pain intensity, respectively, good response to cortico-steroid injections, but not any association with the duration of symptoms or the prognosis. However, scintigraphy appears to be a nonspecific technique and is definitely not suitable for a diagnostic routine measurement or any broad screening. On the contrary is a scintigraphy recommended if the differential diagnosis involves reflex dystrophy, which then shows accumulation in the whole arm and not only in the shoulder area.

Radiotherapy Compared to other less dangerous methods of therapy it does not offer any benefits and should thus consequently no longer be applied on frozen shoulders.

Extra corporal shockwave therapy Again, there is no indication for the extra corporal shockwave therapy in order to achieve any clinical benefit at a frozen shoulder. On the contrary, even an increased restriction of the movements could occur through intensification of the capsulitis and its soft tissue irritation.

Magnetic Resonance Imaging Coronar and axial MR images with intravenous contrast agent, T1-weighted and fatsaturated. Findings are circular contrast agent absorption along the glenohumeral joint capsule, with emphasis on the axillary recess, around the rotator interval and the biceps tendon anchor.[6] Mengiardi et al. defined following MR arthrographic findings as characteristical for frozen shoulders: Thickening of the coracohumeral ligament, thickening of the capsule at the rotator cuff interval and complete obliteration of the fat triangle under the coracoid process, the so-called subcoracoid triangle sign. It is important to mention that the diagnosis of a frozen shoulder, respectively, of an adhesive capsulitis, in spite of all the actual findings and evidences, is still a diagnosis via preclusion.

Management Management of this disorder focuses on restoring joint movement and reducing shoulder pain, involving medications, physical therapy, and/or surgical intervention. Treatment may continue for months, there is no strong evidence to favor any particular approach.[8] Surgical evaluation of other problems with the shoulder, e.g., subacromial bursitis or rotator cuff tear may be needed. Medications frequently used include NSAIDs; corticosteroids are used in some cases either through local injection or systemically. Physiotherapy may include massage therapy and daily extensive stretching.[8] If these measures are unsuccessful manipulation of the shoulder under general anesthesia to break up the adhesions is sometimes used.[8] Hydrodilatation or distension arthrography is controversial.[9]Surgery to cut the adhesions (capsular release) may be indicated in prolonged and severe cases; the procedure is usually performed by arthroscopy.